Notifies a person of:

• eligibility;
• ineligibility;
• copayment amount, if applicable; and
• right to appeal.

If benefits were approved, the notice informs the person of:

• the date benefits begin, also known as the Medicaid effective date; and
• the amount of benefits.

If benefits were denied, terminated or reduced, the notice informs the person of:

• the reason for denial;
• the effective date of the action;
• the person’s right to appeal;
• the address and phone number of free legal services available in the area; and
• that information from a credit report was used, if the information resulted in denial or termination of benefits.

The following forms must be sent at initial certifications with the Form TF0001:

• HIPAA — Notice of Privacy Practices;
• Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement.
• Form H1019, Report of Change, with a prepaid envelope; and
• Form H1204, Long Term Care Options

Provides notice to the state institution of the:

• action taken on the application; and
• amount of income available to be applied to the vendor rate for the applicant or recipient’s maintenance, support and treatment.

Provides advance notice to applicants and recipients who have transferred assets for less than the fair market value or who have home equity that exceeds the limit. The form notifies the person of the:

• amount of the uncompensated transfer and the length of the penalty period;
• possible effect of the transfer of assets on Medicaid services or eligibility;
• possible effect of excess home equity on Medicaid services or eligibility;
• process for claiming undue hardship; and
• opportunity to provide more information about the transfer that may reduce the penalty period.

Send the form within three business days of determining the uncompensated value of any assets transferred for less than the fair market value or excess home equity.

Provides notice to an institutionalized person of retroactive changes in their co-payment. Includes the following information:

• the calendar months involved;
• the adjusted co-payment amount for each month, based on a comparison of projected variable income or incurred medical expenses with actual variable income or incurred medical expenses received;
• totals for the projection period of the amount the facility owes the applicant or recipient and the amount the applicant or recipient owes the facility; and
• the right to appeal.

Provides notice to applicants or recipients with excess resources that they can designate liquid resources as burial funds. Have up to $1,500 in burial funds. excluded from the eligibility determination.

Send Form H1277 to the applicant or recipient before denying for excess resources.

For spousal impoverishment applications, Form H1279 provides notice to the applicant or recipient of the initial eligibility period and the following:

• At the end of the initial eligibility period, only the resources in the name of the institutionalized spouse are tested against the resource limit.
• Interspousal transfers are permitted.
• A transfer-of-assets penalty may be incurred if resources are transferred to anyone other than the spouse.

Provides notice of financial eligibility determination on a referral for Community Attendant Services (CAS) or waiver services.

Provide the following:

• financial eligibility determination from MEPD or Texas Works eligibility staff;
• information requested on a pending application or ongoing case;
• case information not involving an eligibility determination such as a change in address or the authorized representative; and
• changes in co-payment.

Send to the:

• Community Care Services Eligibility (CCSE) case manager for CAS cases; or
• HHSC Program Support Unit (PSU) for waiver cases. Include the co-payment amount, if applicable.

Form TF0001

ME Communication Tool- applications and disposition of pended redeterminations only

Form H0053, Medicaid Buy-In Potential Eligibility Notice

Notice must include each eligible month listed in reverse chronological order, each premium amount, total of all premium amount(s) and premium due date.